Physicians' attitudes toward the legalization of marijuana use.

We asked 303 practicing physicians in general internal medicine, family medicine, gastroenterology, or psychiatry to indicate whether possessing or using marijuana should be considered a felony, a misdemeanor, warrant the issuance of a citation, or be legalized. The position physicians advocated was unrelated to their specialty, experience diagnosing or treating substance abuse problems, their attitudes toward the efficacy of the treatment of drug abuse, or any other work role or habit we measured. Legalization or citation as compared with harsher penalties, however, was more likely favored by physicians who were younger, less religious, politically more liberal, and those less likely to perceive a serious drug problem in society. Legalization was also more likely favored by physicians who themselves had used marijuana, cocaine, and amphetamines but was unrelated to the use of alcohol, cigarettes, or tranquilizers. Although physician opinion should be sought as society deals with the drug problem, this study suggests how physicians'' characteristics may influence the opinions that are rendered.     

Management of alcoholism in the primary care setting.

Primary care physicians can play an important role in managing alcoholic patients. Identifying and treating alcoholism early, before it has interfered with patients'' relationships and work, may increase the likelihood of prolonged recovery. Simple office interventions can help motivate patients to abstain and seek treatment. People who abuse alcohol and are unwilling to abstain can benefit from a recommendation to reduce their intake of alcohol. For alcohol-dependent patients who decide to stop drinking, primary care physicians often can manage withdrawal on an outpatient basis. Selecting an appropriate treatment program for each alcoholic patient is important, and referral to a specialist to assist in matching patients to treatments is often necessary. Primary care physicians also can help prevent relapse. Although disulfiram is of limited value, primary care physicians can support recovery by identifying coexistent psychosocial problems, helping patients to restructure their lives, and ensuring continuity of care.     

Forensic Medicine: An Aid to Criminal Investigation

Forensic medicine is medicine as applied to the problems of the law. The origins of both are hidden in the mists of antiquity, dating from the beginnings of family and tribal life. Recorded human history goes back for 6000 years. Sumeria, Babylon and Egypt all contributed to the development of forensic medicine. Imhotep was probably the first real medicolegal expert. Hippocrates, the Greek physician, and Galen, the Roman, made considerable contributions. Little advance was made during the millenium of the Dark Ages. But Renaissance medicine gave this branch of medicine an impetus in the seventeenth, eighteenth and nineteenth centuries, and in the twentieth, interest in forensic medicine is worldwide. The physician, the coroner, the pathologist, the medical specialist and the forensic laboratory contribute to the investigation of crimes against the person, and to the solution of such problems as identification, untoward deaths, apparent drowning and many others.     

Adolescent health care in a large multispecialty prepaid group practice. Who provides it and how well are they doing?

Adolescents are at risk for pregnancy, sexually transmitted diseases, suicide, homicide, accidents, and substance abuse. Adolescent medicine involves an overlap of many skills needed to provide routine medical care, as well as care for those conditions that require psychosocial assessment. We report the results of a mail survey covering care of this age group by practitioners of pediatrics, internal medicine, obstetrics and gynecology, family practice, and adolescent medicine in a large, multispecialty, prepaid group practice. The mail survey covered 10 areas of adolescent care. Adolescent medicine physicians expressed the highest level of perceived knowledge and competence in these areas, with family practitioners ranked second. More than 50% of internists and pediatricians felt only fair to poor competence for a variety of adolescent conditions, whereas a third of internists and pediatricians reported that they liked to care for adolescents. Physicians in all 4 of the primary care specialties reported a need for a teen health center for both consultation and education. These results are similar to those reported for pediatricians and primary care physicians in private practice and for residents in internal medicine.     

Health problems and health care for adolescents in residential facilities in Quebec.

The health problems of 160 adolescents in four residential facilities of the Quebec social welfare court were studied. At the time of admission 44% had at least one problem requiring consultation with a specialist and 80% had an average of two problems requiring primary care. The medical records of 106 youngsters in two re-education centres were also reviewed and similar results were noted. The health services available, particularly physical examination and laboratory testing at the time of admission and arrangements for referral and follow-up were judged to be insufficient in most centres. Although society has taken custody of these adolescents, no one is responsible for their health care. Since February 1976 the social welfare court residential facilities and the network involved in the care of socially disturbed youngsters have been undergoing reorganization. Health programs and services ought to be part of this reorganization, and private physicians, hospitals and government each should have a role in the establishment and functioning of these programs.     

Annonce des résultats en médecine nucléaire : enjeux et réflexions. «: Informer le patient,ce n’est pas l’obliger à entendre,mais le préparer à comprendre » - Article 7 de la charte du GT Ethique de la SFMN

Announcing ant delivering results to patients from nuclear medicine tests, and particularly with PET imaging, can vary profoundly from a department to another, even from a physician to another. French regulation regarding patients’ information and access to their health data as well as the National Cancer Institute's (Institut national du cancer–INCa) most recent recommendations concerning cancer announcement ask all medical imaging specialists (nuclear medicine physicians and radiologists) to be more implicated in the announcement process. Moreover, and above all legal considerations, it is ethically difficult to refuse any kind of medical communication to a demanding patient and let that patient, sometimes alone, discover the results without any kind of medical comments from the specialist who wrote the report. Such heterogeneity is real and must therefore be understood and explored. The arguments given by physicians who do not give results or who are not implicated in cancer announcement are analyzed in a non-dogmatic fashion to find concrete answers to patients’ legitimate expectancies.     

Behavioral convergence and institutional separation: An analysis of plural medicine in Sri Lanka

In Sri Lanka, as in India, two formally structured systems of medical service exist side-by-side. While Western-style biomedicine is believed to be useful, Ayurvedic medicine is also well established and commonly used. Underlying one explanation for the existence of plural medical systems is the idea that traditional and Western systems of medicine provide unique treatments for distinct problems, and patients having certain characteristics select them accordingly. A brief review of several studies in Sri Lanka suggests, however, that Western and Ayurvedic physicians practice medicine in similar ways, are selected for treatment of very similar symptoms, and from the patient's point of view are aften indistinguishable from each other. A second structural explanation rests on the fact that, as institutions, Western and Ayurvedic medicine have effectively divided up territory and jobs to the satisfaction of each; this division allows for upward mobility, through medicine, for young people from different segments of society. Thus these medical systems persist, not because each provides something unique for patients, but because they provide access to status and power for the physicians themselves.     

Is deleting the digital rectal examination a good idea?

Although the supply of physicians in the United States has doubled during the past 20 years, there is still disagreement as to whether we currently have or should expect a significant surplus of physicians. The evidence suggests that despite the rapid expansion in the pool of available physicians, serious physician shortages persist for certain rural populations, ethnic and occupational groups, and other medically disadvantaged segments of the population. Medical students'' declining interest in rural practice and primary care specialties suggests that problems of geographic and specialty maldistribution may worsen despite a rising population of physicians. It is unlikely that a significant physician surplus will develop unless there is a conscious attempt to limit the proportion of national wealth expended on medical care. Pockets of shortage can be reduced by broadening the availability of health insurance, lessening large income disparities between different specialties, changing the way teaching institutions are reimbursed for their training costs, and supporting direct governmental service programs such as the National Health Service Corps.     

ANALYSIS OF ABSENTEEISM IN INDUSTRY

There are many nonmedical factors that contribute to employee absenteeism in industry. An employee''s total life situation or total environment may be a causative factor in excessive “sick absenteeism.” In many instances the cure for “abnormal” sickness absenteeism is within the province of supervisory personnel, who should look upon abuse of sick leave benefits among employees as morale problems and as evidence of possible maladjustment to the demands of the job or the industry. There are, however, many problems in mental and physical health affecting absence rates in which preventive psychiatry and medicine can make greater contributions. Even truancy and malingering may sometimes be conditions requiring professional medical care.The role of a private physician in determining and certifying the true state of a patient''s health is a most important one economically to industry and the community. The total problem of absenteeism for sickness, as it exists in industry today, points up the need for the most effective cooperation and communication possible between industrial and private physicians. Since no more than 25 per cent of the total work force is employed in industries having in-plant medical programs, the burden of responsibility for the control of absenteeism for sickness rests mainly with private practitioners.     

Poverty in the United States as Defined by Federal Standards—Report of the Bureau of Research and Planning

The subject of this Socio-Economic Report is of tremendous importance to the medical profession because physicians should be aware that future programs for the expansion of health care services will be based and, in fact, are being based upon information which this Report contains. The relationship between poverty and accessibility of health care services is therefore quite direct. So, too, will be the impact upon the profession and the organization of medical practice.The 1966 amendments to the Poverty Act are concerned with neighborhood health centers and a vast array of other programs which will touch every physician and every community which can be identified by the standards indicated in this Report as low income, poor, or near poor. For this reason the California Medical Association Committee on Welfare Medical Programs, among several others concerned with aspects of this problem, is trying to alert every county medical society of developments as well as of the responsibilities they should assume in working with the Office of Economic Opportunity and other community organizations in providing guidance and leadership in structuring programs compatible with the interests of the public and the health care professions.This Report on poverty presents a current and prospective view of the problems and issues to be faced. Unless physicians see the relationship and join in a community effort to aid in resolving an issue which underlies public policy, we shall be looking back five or ten years from now to point out that we failed to take advantage of opportunities to assist in the development of a rational system of medical care for low-income groups.Individual physicians, component medical societies on a grass-roots level and CMA as a state organization should all be concerned with and aware of the facts.     

以服务为导向手术科室服务量考核指标和薪酬分配方法

如何通过服务量指标来体现医务人员的劳动价值,构建一套以服务为导向新的院科两级薪酬分配的指标体系及其操作办法,是目前深化医改的重要课题。文章结合专家咨询方法和数据分析方法,研究临床手术科室的薪酬分配改革办法,系统探讨了新办法的指标选择、权重设置、测算依据、模拟测算、预测效果及其存在问题,阐述了改革办法中应用的两项关键技术——服务量积点和积点价值。     

CHANGING CONCEPTS IN MEDICAL TREATMENT

In a community—even a small one—where physicians established in practice have intensity of purpose, continuing curiosity, healthy skepticism and the spirit of research, the medical atmosphere is one to attract and welcome young physicians who are recently graduated and eager to apply the knowledge gained from the specialists who taught them in medical schools.As the modern laboratory and other facilities and equipment now in use in teaching institutions become available in more and more small communities, general practice remote from the medical centers probably will have increasing allure for neophyte physicians upon whom great influence is being brought to bear to induce them to practice medicine where the need is greatest.Knowledge of the changes in concepts of medical treatment that have taken place in the life-span of the physicians already established in a community will help the young physician fit himself congenially and effectively into the methods of practice of his elder colleagues, with mutual benefit.     

Doing what the patient orders: maintaining integrity in the doctor-patient relationship

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician....I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment....     

Consultant physician to outpatients.

Analysis of the records of the last 450 outpatients referred to me showed that the basic disorder of at least one in three lay in the psyche, and there was a large emotional element in many of the others. None were put on a waiting list for admission. Not only should physicians be generalists most of the time (whether or not they have a special interest) but most medical problems are best dealt with by the GP. Only occasionally can the physician attach a precise diagnosis to a patient who has been an obscure problem to his GP, and the physician''s most important function is to reassure the patient and explain his symptoms. Routine investigations seldom benefit the patient. If there could be a more equitable distribution of GPs of high quality with good back-up facilities fewer general and many fewer specialist physicians would be needed.     

Social medicine and social policy

Social medicine as a term has achieved acceptance in medical education and medical practice, although there is still some question as to its acceptance in reality. The term had its origin in the vigorous nineteenth-century efforts at both medical and social reform, combining the two in a recognition of the intimate connection between social factors and the causation of disease. Henry Ernest Sigerist, a Swiss physician and noted scholar of medical history, formulated the broadest concept in the 1930s, attracting students and a latent American reform movement toward the idea of restructuring medical education as one part of social reform, and indicating ways of restructuring medical practice as another element in improving medical care at the same time. In addition to promulgating the doctrine, he established the policy of examining and describing systems of medical education and medical care in other parts of the world, not only to assist in improving medical care in countries with well-organized systems, but to assist countries with poor resources and lesser organizational capability in meeting the goals of social medicine. Doubt as to the durability of the concept has been expressed, insofar as the recommended improvements have lagged behind the expression, and because so many changes have taken place in the nature of medical practice, medical discoveries, and advances in technology. A closer examination of Sigerist's writings on the subject and evaluation of the circumstances around present-day problems would seem to indicate that the flaw is not in the doctrine, but in the lack of social application.     

Learning to deal with drug-dependent patients: one physician's reflections.

Physicians with a contemporary education may not be adequately trained to deal effectively with drug-dependent patients. This paper details the problems that one physician encountered with such individuals in his practice. A retraining program was set up in which he received basic education in drug dependence and became involved in individual counselling with drug abusers and in research studies on alcoholism and drug abuse. Physicians must exercise caution when prescribing medications that are potentially addictive. They must have a responsible attitude in their care of drug-dependent patients. The assessment and treatment of such patients should be carried out only by a multidisciplinary team of health care professionals. These principles are best inculcated by the proper exposure of medical students to substance-abuse problems and by the availability of appropriate courses and studies in this area to practising physicians.     

Knowledge, Attitudes, and Practices of Physicians in Tomsk Oblast Tuberculosis Services Regarding Alcohol Use Among Tuberculosis Patients in Tomsk, Russia

In recent years, the Russian Federation has seen a dramatic rise in morbidity and mortality from tuberculosis (TB), attributed in part to an increase in alcohol use disorders (AUDs), which are associated with worse TB treatment outcomes. This study describes the knowledge, attitudes and practices of physicians who treat TB patients in Tomsk, Russia. We conducted semistructured interviews with 16 TB physicians and 1 addiction specialist. Interviews were audiorecorded, transcribed, translated and systematically analyzed. We identified four key domains: definitions of alcohol use and abuse and physicians’ knowledge, attitudes and practices regarding these problems. Physicians described patients as largely precontemplative and reluctant to seek treatment. Physicians recognized their limited knowledge in diagnosing and treating AUDs but expressed interest in acquiring these skills. Few options are currently available for treatment of AUDs in TB patients in Tomsk. These findings suggest that Tomsk physicians are aware of the need to engage AUDs in TB patients but identify a knowledge gap that restricts their ability to do so. Training TB physicians to use simple screening instruments and deliver evidence-based alcohol interventions improves TB outcomes among patients with co-occurring AUDs.     

Factors associated with physician recognition and treatment of alcoholism.

We surveyed internists, family physicians, and psychiatrists regarding their clinical experiences in assessing and treating alcohol abuse, practice characteristics, political and religious beliefs, attitudes toward substance abuse, beliefs about the efficacy of treatment, personal experiences with substance use, and sociodemographic variables. Despite the high prevalence of alcohol abuse, a third of the physicians neither regularly counseled nor referred any patients for outpatient rehabilitation, and more than half had not referred anyone for inpatient treatment. A greater breadth of experience treating alcohol problems was positively correlated with the volume of outpatients and inpatients seen, younger age, more work in primary rather than specialty patient care, less academic work, a stronger belief in the efficacy of treating alcoholism, membership in the Republican party, and a greater religiosity.     

Evaluation of the development of psychosomatic medicine in a large university hospital in Turkey

The purpose of this study was to evaluate the development of psychosomatic medicine at our university hospital in Istanbul, which has an inpatient capacity of 3,000. Changing patterns of utilization of psychiatric service were analyzed in two 1-year surveys five-year intervals (1998, n=888) - (2003, n=1609). Psychiatric referrals were analyzed with regard to rate of consultation, demographic characteristics, departments making referrals, reasons for referral, psychiatric diagnoses and patterns of psychiatric intervention. Psychiatric consultation request, consultation reply and medical psychiatric examination forms were used. In evaluating the data, consultation rate was seen to have doubled over the five intervening years. Significant changes were also noted in the demographic characteristics of patients (e.g., more men, older mean age). The most prevalent disorders in both groups were depressive disorder and adjustment disorders. Alcohol and substance abuse remained as a small group. The gradual increase in the utilization of psychiatric services can be attributed to service and education-related variables.